Outpatient claims grew increasingly complex between 2004 and 2021 in emergency departments, urgent care centers and physician's offices — even among specific, common diagnoses like urinary tract infections and headaches — according to a Feb. 27 Peterson-KFF Health System Tracker report.
Researchers reviewed private, large employer-based insurance claims from the Merative MarketScan Commercial Claims and Encounters database for non-elderly people, according to the report. They examined the distribution of code levels over time for all evaluation and management claims and for specific diagnoses.
Six things to know:
1. Taking claims from all three settings, Level 3 claims decreased from the majority of claims (60 percent) in 2004 to less than half (45 percent) in 2021.
2. Level 4 claim frequency jumped from 19 percent in 2004 to 37 percent 2021.
3. Level 5 claims doubled from 3 percent in 2004 to 6 percent in 2021.
4. In emergency departments, Level 4 and 5 claims now make up the majority of claims. Level 4 claims increased from 25 percent in 2004 to 35 percent in 2004. Level 5 claims increased from 8 percent to 25 percent.
5. Outpatient evaluation and management spending was 4 percent higher in both physician offices and emergency departments in 2021 than it would have been if visits were coded at the same levels in 2011.
6. More people in the U.S. have been diagnosed with comorbid conditions over time, which may contribute to the complexity of outpatient claims, according to the report. But researchers also found that trends in coding levels are also reflected in diseases that are less likely to be worsening over time or in which comorbidities have a smaller impact.